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e lectronic s ubmission of Medical Documentation (esMD) electronic Determination of Coverage ( eDoC ) Workgroup Charter Review. January 30 , 2013. Welcome and Introductions. Melanie Combs-Dyer, RN Deputy Director, CMS / OFM / Provider Compliance Group. Dan Kalwa

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electronic submission of Medical Documentation (esMD)electronic Determination of Coverage (eDoC) WorkgroupCharter Review

January 30, 2013


Welcome and Introductions

Melanie Combs-Dyer, RN

Deputy Director,CMS / OFM / Provider Compliance Group

Dan Kalwa

Health Insurance Specialist,CMS / OFM / Provider Compliance Group

Michael Handrigan, MD

Medical OfficerCMS / OFM / Provider Compliance Group

Robert Dieterle,

Initiative Coordinator

Viet Nguyen, MD

Chief Medical Information Officer

Systems Made Simple, Inc.

Mark D Pilley, MD AAFP, AADEP, ABQAURP

Medical Director

StrategicHealthSolutions, LLC

2




Edoc general workflow
eDoC General Workflow

Patient

LCMP

Physician

Specialist /

Service Provider

Templates and Rules

Payer

5


Scope
Scope

Out of Scope

Specific provider service implementations

EHR implementations

Provision of Information exchange services (e.g. HISPs for Direct)

  • In Scope – Phase 1

  • Structured and unstructured data requirements

  • Exchange standards

  • Digital signature requirements

  • In Scope – Phase 2

  • Templates for Structured Data Capture (SDC)

  • Decision Support (rules, data capture, order sentences and behaviors) (HeD)


Edoc pmd workflow
eDoC PMD Workflow

Patient

Signed Document

3

11

1

LCMP

Physician

DME Supplier

2

5

6

10c

4

8

7

9a

10a

10b

9b

Templates and Rules

Payer

Payer

7



Structured information for pmd
Structured Information for PMD

  • Based on clinical template developed by CMS

    • Available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Downloads/Suggested-PMD-Electronic-Clinical-Template-v98-posted-11-02-12.pdf

  • Supports

    • Data collection by providers during face-to-face evaluation

    • Reporting of clinical information for coverage determination

    • Clinical decision support and automated determination of coverage

9


Components of pmd clinical template
Components of PMD Clinical Template

  • Chief Complaint

  • History of Present Illness

  • Past Medical History

  • Review of Systems

  • Physical Exam

  • Patient Assessment and Plan

  • Physician Information and 7 Element Order

  • Components focused on data to support a PMD order and coverage

10


Evaluation process for pmd clinical template
Evaluation Process for PMD Clinical Template

  • Examination of individual clinical elements for each section of the template

  • Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems)

  • Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components

  • Develop Templated CDA based on consensus and best practices

11








Edoc timeline
eDoC Timeline

July ‘13

Mar ‘13

May ‘ 13

Aug ‘13

Jun ‘13

Feb ‘13

Apr ‘13

Pre-Discovery

Workgroup Charter/Scope

Kick-Off

PMD Phase 1

Pilots (TBD)

PMD Phase 1

Implementation Guide

Use Case #1: PMD Phase 1

Standards/Data Model/Harmonization

PMD Phase 1

Sub Workgroup PMD Structured Data

PMD Phase 2

Implementation Guide

Use Case #1: PMD Phase 2

Standards/Data Model/Harmonization

PMD Phase 2 (TBD)

Sub Workgroup PMD Data Capture Template

Sub Workgroup PMD Decision Support

18

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Summary
Summary

eDoC workgroup identifies Best Practice for:

  • Payer interaction with providers for determination of coverage

  • Developing, delivering and using structured documentation templates to support coverage determination

  • Developing and instantiating decision support rules to facilitate provider decision making in light of payer standards

  • Addressing Author of Record requirements

  • Secure electronic communication between payers, provider, suppliers and beneficiaries

  • Creating implementation guides for payers and providers (usually via HIT vendors) for all required eDoC processes and transactions

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